Photo: U.S. Embassy South Africa/Flickr (CC BY 2.0)
The U.S. government’s President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest bilateral, disease-specific foreign assistance program in the world and the cornerstone of the U.S. global health portfolio. PEPFAR was created nearly 20 years ago in response to the global HIV/AIDS pandemic. Initially the program concentrated the majority of its efforts in sub-Saharan Africa, which, at the time, had more than 27 million people living with HIV but only 50,000 people on antiretroviral treatment. To date, funding for PEPFAR programs has topped $110 billion, and the initiative supports prevention, testing, and treatment efforts in more than 50 countries. The program is credited with supporting at least 20 million people on antiretroviral treatment, saving 25 million lives, and further galvanizing the broader global HIV/AIDS response that exists today, ultimately helping to change the trajectory of the HIV/AIDS pandemic.
Today, a pandemic is once again testing countries around the world, especially in lower-income countries where health systems remain fragile and vulnerable to external shocks. In the countries where PEPFAR supports HIV service delivery, commodities distribution, and research, the 2020 arrival of a dangerous new respiratory virus, SARS-CoV-2, presented challenges and opportunities for the program. While there was considerable concern over the potential for the Covid-19 pandemic to be especially disruptive in countries with a high HIV burden, PEPFAR-supported initiatives have proven to be uniquely positioned to respond to Covid-19. Over the course of the pandemic, PEPFAR programs have been adapted to help minimize HIV service disruptions and address the Covid-19 needs of people with HIV, demonstrating that the program can pivot, be agile, and respond to non-HIV threats by leveraging its capabilities.
With a new global AIDS coordinator in place since June 2022 and a new five-year strategy published on December 1 (World AIDS Day), PEPFAR is charting an ambitious path focused on closing gaps in the HIV response, including those that have widened during the pandemic; redoubling efforts to help the countries where it operates achieve epidemic control; and ensuring the sustainability of its efforts. The new strategy is also being launched against a policy backdrop of flat funding, a new Congress, and an upcoming reauthorization in 2023, as well as a broader U.S. government approach focused on health systems strengthening (HSS) and pandemic preparedness and response (PPR). As these efforts move forward, the program will face important questions, not only in terms of how it will continue to address HIV but also regarding how and to what extent the PEPFAR platform can be leveraged to advance a broader global health security agenda.
Recognizing that people living with HIV who are infected with SARS-CoV-2 are at greater risk for severe illness, high priorities for PEPFAR programs during the acute phase of the pandemic included ensuring continuity of PEPFAR-supported services during periods of quarantine and lockdown and protecting highly vulnerable people and staff from exposure to infection with coronavirus.
Guidance documents prepared for distribution to country coordinators and program implementers focused on minimizing HIV service disruption, but they also covered such issues as mask-wearing for health workers and other infection prevention and control activities. As the Covid-19 pandemic response entered a second year, guidance also outlined the conditions under which PEPFAR-supported programs could support Covid-19 vaccine delivery for people receiving care for HIV or HIV and tuberculosis.
Since the start of the Covid-19 pandemic, PEPFAR-supported assets have been successfully engaged to respond to the pandemic in many ways. These have included the use of PEPFAR-supported laboratory resources to process Covid-19 tests; training and deploying health workers in PEPFAR-supported clinical sites to administer Covid-19 vaccines; and ensuring the delivery of diagnostic tools and personal protective equipment for health staff through PEPFAR-supported supply chains.
Important lessons from the past two decades of HIV efforts, including research and service delivery, as well as advocacy initiatives, have also shaped the response to Covid-19. These include a programmatic emphasis on equity and community engagement, as well as on universal access to prevention, diagnostics, and treatment, as important aspects of pandemic response.
Since Dr. John Nkengasong was sworn in as the U.S. global aids coordinator in June 2022, PEPFAR has been developing its next five-year strategy. The drafting process was informed by a range of stakeholders, including country governments, multilateral and other partners, U.S. government entities, civil society representatives, and other experts. Nkengasong has called for a “reimagined” global health response, including for PEPFAR to achieve HIV-related targets, while also leveraging the program to strengthen health systems and support countries’ abilities to respond to emerging health challenges, such as another pandemic. The new strategy reflects this vision and builds upon an initial strategic approach presented during the 24th International AIDS Conference held in Montreal, along with a strategic direction document released during the United Nations General Assembly meeting in September.
PEPFAR’s commitment to a broader role in PPR is established in the strategy’s purpose, which states that PEPFAR will work toward ending the HIV/AIDS pandemic by 2030, “while sustainably strengthening public health systems.” One of five goals supporting PEPFAR’s purpose focuses on improving “partner country public health systems and health security” to strengthen capabilities to address HIV as well as “other health threats.” Further, the third of five strategic pillars to achieve its goals is squarely focused on health systems and security and calls for leveraging “PEPFAR-supported platforms and public health systems to respond to health security threats and enhance and improve delivery of health services with our partner countries.” One of the six focus areas under this pillar is centered on strengthening PPR efforts and calls for coordinating with governments to identify opportunities where PEPFAR can support country activities under National Action Plans for Health Security and help PEPFAR-supported health workers more effectively prepare for and manage disease outbreaks.
With approximately 30 million people in PEPFAR-supported countries living with HIV, reaching HIV targets will require a long-term effort and significant resources. However, there have been declines in donor government funding for HIV programs, and partner countries face a myriad of interconnected challenges, including Covid-19 and the related economic fallout, inflation, climate change, and other competing policy priorities, all of which can negatively impact countries’ ability to optimally manage their HIV epidemics. U.S. funding for PEPFAR has been relatively flat in recent years, except for an injection of emergency funding in fiscal year (FY) 2021 intended for bilateral HIV efforts and to support the Global Fund to Fight AIDS, Tuberculosis and Malaria in helping countries respond to Covid-19. In a scenario of limited funding and competing priorities for scarce global health dollars, how will PEPFAR-supported programs help close the gaps in access to HIV prevention, testing, and treatment while more deliberately strengthening health systems and advancing the goals of PPR?
How PEPFAR-supported programs will intersect with and complement other administration health initiatives, such as the Biden-Harris Administration Global Health Worker Initiative, or other priorities, such as the Pandemic Fund at the World Bank, is also an important question to consider. The U.S. Department of State’s recent announcement that it will create a new bureau on global health security and diplomacy that brings together the responsibilities of the Office of International Health and Biodefense, the coordinator for global Covid-19 response and health security, and the Office of the U.S. Global AIDS Coordinator offers an opportunity for careful consideration of the benefits and challenges of integrating the HIV and PPR agendas.
As the 20th anniversary of PEPFAR approaches, the program faces reauthorization in 2023, just as a new Congress takes office following the 2022 midterm elections. While the program has been reauthorized three times and has enjoyed strong bipartisan support since its inception, the arrival of new members means that there are fewer established congressional voices who have longer-term memory and a history of supporting the program. How members of Congress will consider the program now that it is 20 years old and perhaps eclipsed by Covid-19 in the minds of many constituents remains to be seen.
As implementation of the new PEPFAR strategy moves forward, continuing to support countries’ efforts to strengthen their health systems and prepare to respond to future pandemics promises to be an important element of the work over the next five years. Bringing PEPFAR’s bold new vision for its next phase to fruition will require accurately cataloging the ways in which PEPFAR assets have supported Covid-19 response; capturing lessons from the pandemic experience; and ensuring that integration of HIV and PPR work serves both to close gaps in the HIV response, including those that widened during Covid-19, and to enhance readiness for future health crises.
Alicia L. Carbaugh is a senior associate (non-resident) with the Global Health Security Program at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Katherine E. Bliss is senior fellow and director, immunizations and health systems resilience, with the Global Health Policy Center at CSIS. The authors thank Mackenzie Burke for her research assistance.
